26564 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDIN,-ELF RIf,AL PERM['I'NO.
APPIACATION/PERMIT PLUMBING-MRCHANICAT, ^/N 1�
BUILDING DIVISION BUILDING'PROJECTIDEN'I'INICATIUN L Vh VN 6
BUILDING ADDR17SS: SANITARY NO. APPLICATION SUB///MII TPAL DAT1;.
UNIT# LOP'# gGi -A�y
DOWNERS E: PHONE: - CONTRA OR'S NAME: - LIC NO: _
N/C CONfROLN
dRCHIFECUE INFER: WCL LICNO: AD ISS _ O
Y L •�
GON'TACI. PHONE: -
Q'I'Y, ELECTRIC PERMIT FI?G BUILDING PERMITINFO
>/ BL? ELECT PLUMB MPCU
<x- PERMIT ISSUANCE
LICENSED CON'TRACTOR'S DIiCLARATION APPLIANCES-RESIDENTIAL.
PCZ Ihereby effinnthao lam licensed underprovisiereofCTapoer9(commencing with JOB DESCRIPTION
1x100 Section 7000)of Division 3 nfthe Busineesand Professions Cudgdnd my license is in PANELS
w V Mme- lull force and effect.
QZ.y Licenc ClassLiUPT0200AMB
�i=y eez,, .AContractor - 201-I"AMPS
Z OyZ ARCHITECTS DECLARM[ON OVER IOIg1AMl'S SQ.FL FLOOR AREA $/SQ,FT.
O Z'-0 1 miderslund my plans shall be must an public reomb.
j_trLl W SIGNS ELECTRICAL.
gR, LicenuJ fmfessinmJ
affiOWNER-BUILDRR DECLARATION SPECIALCIRCUIT/MISC,
Jq°��OaF I hereby affirm It.,1 am exempt from the Comecmr's License Law for the
ssd34m following mason.(Section 7031.5.Business and Professions Cale:Any city or county TEMP.METER OR POLE INST. _�—
�is, which requires a permit to construct,altar,improve,demolish,or repair any stmc,ure
a� pnonoi,sisome-,alsorv,mm,the applicant for,ucbpemuLoo file a signedammment POWER DEVICES __-���
ty_p0z that he is licensed pursnam to the provisions offle Contractor's License Law(Chapter
p' oLL 9(commencingwi,h Section 7000)ofDivision 3 ofthe Business and Professions Cole) SWIMMIN PO(rf. Ir r VALUATION �y.f -
Q1.2, Oaths,he ix exempubertfrdmandthe osis for the alleged exemption.Any violation of SWI .IIES� �•l"d
rr,Q Section 7031.5 by any appi kart fora Penni,subji,cmderip,hnert m n civil penalty of OUTI ITS FIXTIr
not mom hen five hundred dollars(5500). s d
= NEW RLSID I R .F.
Fym ❑ I,axnwneroUhepropeny.mmyemployees with wegesastheirsolecompensmien, _ STORIE TYPE CONS'PRUCf10N
IaL3 willd.1heworIcandthestruclure kneut imcndederolmcd forsale(Sec.7044,Business _1—--
and Pmfescions Cade:The CommctrA License Law does net upply m an owner of
property whabuildsorimprovesthecaumicdwhodees such work himeelfonhrough has OCC GROUP RIS.DNITS
own employees,provided that such improvements uta not intended m offered outside.If,
however,,ba building nrimpmvamem ix solJ within one yeandmmpinion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ole.).
❑ 1,as owner ol'the property,am excmfivelyenntmedng with licensed comsectors to QTY, PLUMBING PERMIT FEE MOOD #ENE APN
instruct the project(Sec.7044,Business and Professions Cale:)The Contractor's
License Lawdoesnot apply loan ownerofpropeny,whobuilds orimprovcvhereon,and PERMITISSUANCE
whocemractsforsuch projects with acoutmemgsl licievecipursuantothe Conhzcusrs ALTER GRAIN If FEE SUMMARY
Llu se Law. (HAd
❑nl am exempl under Sec. ,E&PC for this reason BACK FLOW PROTECT.DEVICE OUT:IDI?FEE
SANITARY YN
Owner Date RFCEIPTp
DRAINS-FLOOR,ROOF,ARG,COND.
WORKMAN COMPENSATION UECGRA'f10N SCHOOL FAX Y_N
❑ Iberebymfinn thalhuveaccrtifeme,fdo.py,hosf(Slnure,uriceb C.) hiof RECP.IfT#
Worked Compensation lnsunnce orecenified copy,hereof(Sec.lBoo,LubCJ which I.IXTURIS-P[R TRAP PARK FEF, YN
Pors NI employee's tndenhis permit/ GAS-EA.SYSTEM-1 INC.4 OUTLIOS RECEIP #
licy# BUILDING DIVISI NFEES
Company GAS-EA.SYSTEM-OVER 4(13A) PLANCHECK FGF:
❑ Ccnified copy is hereby famished. la
❑ Certilice copy ix filed with the city inspection division, GRGSI/INDUSI'RL WASTE INTERcErEYER GRADING HE
CERTIFICATE OF EXEMPTION I-MOM WORKERS' GREASETRAP SOBS FEE
COMPENSATION INSURANCE
('I historrionneadire bccomple,ed if the permit is foroce bandmddellmr (SIIg) SEWER-SANITARY-STORM EA.200111'. ENERGY FEE
mless.)
(certify thatimM1eperforman<enf,he work for which thispennio is iuued,lshall WATER HEATER W/VENT/ELECTR
not employ any person in any m a,m become subject to the Workers' PAID
Compensation Lawsof California, Date so WATER SYSTEMffREATING Deleff V R cello#
O Z Applicant
Z 0 NOTICE TO APPLICANT.If,after making this CeniRcateof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-, 4 become object to,he Worker's Gsmpensn,lon provisions ofine Labor Code,you must
a 7 fnnhwith comply with sol ch provisions lir this petmi,shall be dmF
deemed revoked. BUILDING
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
rrCJJ Ihereby affirm that there is a construction lentling agency l m the performance of TOTAL: ELECTRIC IEE
U O the work for winch this permit is issued(Sec.3097,Civ.CJ
Lender',Name
U Lender's Address QTY. MECHANICAL PERMIT FEF. PLUMBING ME
1 certify that I have read flus application and nam the,the im,ve information is
coned.Ingreemenmply with all city anticounty oNinanecs and mete laws relaxing oo PERMI'T ISSUANCE MF,CI IANICAL PER
huilding conswction.and hereby authorize representatives of this city to enter upon the CONSTRUCTION T
C) shove-nentimed pmpady for i,sspocdm particulate. ALTER OR ADD TO MECI I.
JX
(We)agree m save,indcmni harmless the City of Cupertino against
liuhilities,judgmcros,costs and ex nses whit they in any way accrue against said City AIR HANDLING UNIT(TO I LIIDO CFM)
n consegnenc a graining of this perm
AIR HANDLING UNIT(OVER 10,010 CFM)
gnamre of ppli nUCo ma am EXHAUST HOLD(W/DUCTE
PAID
IIA RDWSMA'I'ERIALSDISCLOSURE HEATING UNIT(TO 100,1100 BTU) .Oma Receipt#
,1l the applicant or future building cecupem store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) I
as defined by the Collection Municipal Code,Chapter 9.12,and the Health and Safetyall
Cade,Sw,l 25532(u)'1
0Yes ❑No VEM'ELATION PAN(SINGLE RESID)
Will the applicant ur future buildingsccupanmucquipmcm ordevices whichemit
BOILER-COMP(3HP OR 1W.000 B1'UI ISS DATE
baeardous all contemintems n,defined by in,Buy Area Air Quality Management BOILER-COMP(OVER 11101000 B'IL) u� 22 199
District?
❑Yes ❑No NEWRGSLDEN'TIALMECH. SQ.IT.
1 have read the hazardous materials requirements under Chapter 6.95 of the oil I, I✓f V
Celifomia Health&Safety Cede,Sections 25505,25533 and 25534. I understand,hat VrCn III�(�
if the building does not
ments ly have amn a that it i is myresponsibilityenmity the
occupant upas of the rcyuinmentx which must he met Prior to issuance of a Certificate of
Occupancy. '
Owner or authorized ngcar Date TOTAL:I ISSUED BY:
OFFICE